Reviewed September 2022

Am I perimenopausal? Coming to terms with change

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Perimenopause, or climacteric, is the transition phase that occurs before your periods finally stop. This point is called the menopause, and by definition occurs when you’ve had no periods for 12 months. In the UK, the average age people reach menopause is 51, while perimenopause tends to occur in the mid to late forties.1

During perimenopause you will experience many changes, often both physical and mental. While some who have experienced problematic bleeding may welcome the end of their period, for many others the residual effects can make them feel different in an unrecognisable and unwelcome way. As many of the changes that occur can feel alien, an understanding of what to expect can be reassuring. This article discusses the key changes and the effects they may have on your body to better prepare you for the transition when the time comes.

Triggering the change

Cisgender women are born with multiple follicles in their ovaries that gradually deplete as we get older. These follicles mature into eggs and if fertilised with a sperm become an embryo that forms into a baby. The follicles secrete a hormone called oestrogen in response to stimulation from other hormones released by the brain. During menopause, the number of follicles in an ovary will have diminished, therefore dramatically decreasing the amount of oestrogen released into the body. This is thought to be mainly causative of perimenopausal symptoms.2

However, the process of change is complicated, and we do not fully understand all the mechanisms involved. For example, exactly how oestrogen reduction affects the temperature control systems of the body to produce a hot flush is not precisely known.3

Other processes also occur as we get older, such as the decrease in the hormone melatonin that regulates our sleep.4 For some, this can upset the natural rhythm that controls a good night’s rest, which can contribute to the difficult changes experienced during this time.

What physical symptoms can I expect?

Everyone who menstruates will experience the eventual cessation of periods due to change in the ovaries and depletion of oestrogen and other hormones. Before this occurs, you may find the length between your periods extends, or perhaps evens shortens. You may also find that you are bleeding more heavily.5

If you notice any vaginal bleeding or blood-stained discharge after 12 months of no bleeding, it is important that you see your doctor urgently as this is classed as postmenopausal bleeding. Your doctor will investigate to rule out the possibility of cancer, however often enough this can be explained by other, more common causes — most of which are not sinister.

Lack of oestrogen stimulation in the vaginal tissue can cause dryness in this area which can be uncomfortable and cause pain during sexual intercourse.6 Explaining the reason for your discomfort to your partner can help them to understand the process your body is going through. You can try over-the-counter lubricants and vaginal moisturisers, and also discuss options such as oestrogen creams and HRT (hormone replacement therapy) with your doctor. The latter may also be an option for those women dealing with recurrent discomfort when passing urine that is linked to oestrogen reduction.

Similar processes of oestrogen decline at the tissue level can also lead to thinning of the skin, hair loss, and weak nails. This can cause considerable distress as you might feel you appear physically different, which can lead to confidence issues and effects on mood. If you are troubled by these symptoms and are in doubt as to whether they are caused by the menopause, do discuss it with your doctor as they can also be linked to other causes such as low iron levels and an underactive thyroid gland, for which you may need blood testing. Psychological distress should also be mentioned to your doctor if you feel unable to cope with your symptoms.

Many people will also experience hot flushes during perimenopause. The sensation of a hot flush involves a burning feeling on the face, neck and chest area with associated sweating, and usually lasts a few minutes. Unfortunately, these may carry on for more than seven years for some people.7 The good news, however, is that there are both non-hormonal and hormonal prescription medicines available to manage this that you should speak to your doctor about.

What effects can I expect on my well-being?

When occurring at night, hot flushes can disrupt sleep, and lead to irritability and effects on mood if they are experienced long-term. Changes during perimenopause can have effects on mood, such as anxiety, and depression, with those who have previously experienced depression perhaps more likely to encounter this.8

If you feel you may be have psychological symptoms, please do not suffer alone. Accessing support via therapies such as cognitive behaviour therapy (CBT) and consulting with your doctor for a comprehensive assessment and discussion of the options can help you to manage and regain your quality of life.

The other effect you may notice during this transition is the effect on your drive and desire for sex. This is thought to be due to hormonal changes, and can cause significant impact to those in an intimate relationship who want to maintain their sex life. Open discussion with your partner explaining that this is a normal part of perimenopause can help to distill feelings of guilt or even rejection. If this is causing significant implications for you do consult with your doctor.

Are there any long-term effects?

Again, oestrogen depletion due to menopause is thought to contribute to increased risk of cardiovascular disease (including heart attacks and strokes)9 and osteoporosis (weakened bones more at risk of fractures).10 If you enter menopause early, which is said to be when you’re between the ages of 40 to 45, your risks of this increase and you should consult with your doctor — HRT may be suggested as a way to minimise risk.

Leading a healthy lifestyle by exercising regularly, minimising caffeine and alcohol intake, ensuring you’re getting enough calcium, and quitting smoking can all help to manage symptoms during this transition. Many people often enquire about herbal therapies, believing them to be more “natural” with less side effects. It is worth bearing in mind that information on evidence and safety for these products is limited, and herbal medicine in the UK is often not subject to the same regulation as licensed drugs.11

Perimenopause can be a challenging time, but knowing what to expect and that options are available to help you manage most elements will hopefully make this a less daunting transition.

Featured image is two older people sitting together at the edge of a pier, facing a lovely beach. They are speaking to each other and appear to be having a good time. Their backs are to the camera

Last updated September 2022
Next update due 2025

Perimenopause, or climacteric, is the transition phase that occurs before your periods finally stop. This point is called the menopause, and by definition occurs when you’ve had no periods for 12 months. In the UK, the average age people reach menopause is 51, while perimenopause tends to occur in the mid to late forties.1

During perimenopause you will experience many changes, often both physical and mental. While some who have experienced problematic bleeding may welcome the end of their period, for many others the residual effects can make them feel different in an unrecognisable and unwelcome way. As many of the changes that occur can feel alien, an understanding of what to expect can be reassuring. This article discusses the key changes and the effects they may have on your body to better prepare you for the transition when the time comes.

Triggering the change

Cisgender women are born with multiple follicles in their ovaries that gradually deplete as we get older. These follicles mature into eggs and if fertilised with a sperm become an embryo that forms into a baby. The follicles secrete a hormone called oestrogen in response to stimulation from other hormones released by the brain. During menopause, the number of follicles in an ovary will have diminished, therefore dramatically decreasing the amount of oestrogen released into the body. This is thought to be mainly causative of perimenopausal symptoms.2

However, the process of change is complicated, and we do not fully understand all the mechanisms involved. For example, exactly how oestrogen reduction affects the temperature control systems of the body to produce a hot flush is not precisely known.3

Other processes also occur as we get older, such as the decrease in the hormone melatonin that regulates our sleep.4 For some, this can upset the natural rhythm that controls a good night’s rest, which can contribute to the difficult changes experienced during this time.

What physical symptoms can I expect?

Everyone who menstruates will experience the eventual cessation of periods due to change in the ovaries and depletion of oestrogen and other hormones. Before this occurs, you may find the length between your periods extends, or perhaps evens shortens. You may also find that you are bleeding more heavily.5

If you notice any vaginal bleeding or blood-stained discharge after 12 months of no bleeding, it is important that you see your doctor urgently as this is classed as postmenopausal bleeding. Your doctor will investigate to rule out the possibility of cancer, however often enough this can be explained by other, more common causes — most of which are not sinister.

Lack of oestrogen stimulation in the vaginal tissue can cause dryness in this area which can be uncomfortable and cause pain during sexual intercourse.6 Explaining the reason for your discomfort to your partner can help them to understand the process your body is going through. You can try over-the-counter lubricants and vaginal moisturisers, and also discuss options such as oestrogen creams and HRT (hormone replacement therapy) with your doctor. The latter may also be an option for those women dealing with recurrent discomfort when passing urine that is linked to oestrogen reduction.

Similar processes of oestrogen decline at the tissue level can also lead to thinning of the skin, hair loss, and weak nails. This can cause considerable distress as you might feel you appear physically different, which can lead to confidence issues and effects on mood. If you are troubled by these symptoms and are in doubt as to whether they are caused by the menopause, do discuss it with your doctor as they can also be linked to other causes such as low iron levels and an underactive thyroid gland, for which you may need blood testing. Psychological distress should also be mentioned to your doctor if you feel unable to cope with your symptoms.

Many people will also experience hot flushes during perimenopause. The sensation of a hot flush involves a burning feeling on the face, neck and chest area with associated sweating, and usually lasts a few minutes. Unfortunately, these may carry on for more than seven years for some people.7 The good news, however, is that there are both non-hormonal and hormonal prescription medicines available to manage this that you should speak to your doctor about.

What effects can I expect on my well-being?

When occurring at night, hot flushes can disrupt sleep, and lead to irritability and effects on mood if they are experienced long-term. Changes during perimenopause can have effects on mood, such as anxiety, and depression, with those who have previously experienced depression perhaps more likely to encounter this.8

If you feel you may be have psychological symptoms, please do not suffer alone. Accessing support via therapies such as cognitive behaviour therapy (CBT) and consulting with your doctor for a comprehensive assessment and discussion of the options can help you to manage and regain your quality of life.

The other effect you may notice during this transition is the effect on your drive and desire for sex. This is thought to be due to hormonal changes, and can cause significant impact to those in an intimate relationship who want to maintain their sex life. Open discussion with your partner explaining that this is a normal part of perimenopause can help to distill feelings of guilt or even rejection. If this is causing significant implications for you do consult with your doctor.

Are there any long-term effects?

Again, oestrogen depletion due to menopause is thought to contribute to increased risk of cardiovascular disease (including heart attacks and strokes)9 and osteoporosis (weakened bones more at risk of fractures).10 If you enter menopause early, which is said to be when you’re between the ages of 40 to 45, your risks of this increase and you should consult with your doctor — HRT may be suggested as a way to minimise risk.

Leading a healthy lifestyle by exercising regularly, minimising caffeine and alcohol intake, ensuring you’re getting enough calcium, and quitting smoking can all help to manage symptoms during this transition. Many people often enquire about herbal therapies, believing them to be more “natural” with less side effects. It is worth bearing in mind that information on evidence and safety for these products is limited, and herbal medicine in the UK is often not subject to the same regulation as licensed drugs.11

Perimenopause can be a challenging time, but knowing what to expect and that options are available to help you manage most elements will hopefully make this a less daunting transition.

Featured image is two older people sitting together at the edge of a pier, facing a lovely beach. They are speaking to each other and appear to be having a good time. Their backs are to the camera

Last updated September 2022
Next update due 2025

Dr. Nupur Yogarajah, BSc Hons MBBS DRCOG PgCert Clin Ed MRCGP

Nupur, a GP, graduated from the Royal Free & University College Medical School in 2006 and after rotating through various specialities she gravitated towards General Practice as it offered continuity with her patients and diversity in her caseload. She has particular interests in women’s, children’s, and sexual health, as well as medical education. Managing a variety of female patients over the years has given her experience of the common queries and misconceptions regarding women’s health. She is passionate about delivering health information in a digestible and accessible way, making The Femedic an ideal opportunity for her writing.

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References

  1. NICE, Menopause, Clinical knowledge summary, National Institute of Care and Excellence, March 2022, [online] [accessed 9 September 2022]
  2. Heffner, L.J., and Schust, D.J., The Reproductive System at a Glance, 4th edn, London, Wiley-Blackwell Sciences Ltd, 2014, pp 56-57
  3. Pachman, R., et al., Management of menopause-associated vasomotor symptoms: Current treatment options, challenges and future directions, International Journal of Women’s Health, no. 2, 2010, pp. 123–135
  4. Wurtman, R.J., Age-Related Decreases in Melatonin Secretion – Clinical Consequences, The Journal of Clinical Endocrinology and Metabolism, vol. 85, no.6, 2000, pp. 2135-2136.
  5. NICE, Menopause, Clinical knowledge summary, National Institute of Care and Excellence, March 2022, [online] [accessed 9 September 2022]
  6. Heffner, L.J., and Schust, D.J., The Reproductive System at a Glance, 4th edn, London, Wiley-Blackwell Sciences Ltd, 2014, pp 56-58
  7. Abdi et al., Hops for Menopausal Vasomotor Symptoms: Mechanisms of Action, Journal of Menopausal Medicine, vol. 22, no. 2, 2016, pp. 62–64.
  8. Santoro, N., et al., Menopausal symptoms and their management, Endocrinology & Metabolism Clinics of North America, September 2015, vol 44, no. 3, pp 497-515
  9. Iorga, A., et al., The protective role of estrogen and estrogen receptors in cardiovascular disease and the controversial use of estrogen therapy, Biology of sex differences, 2017, 8:33
  10. Sözen, T., et al., An overview and management of osteoporosis, European Journal of Rheumatology, March 2017, vol 4, no.1, pp 46-56
  11. Royal College of Obstetricians and Gynaecologists (RCOG), Alternatives to HRT for the Management of Symptoms of the Menopause, Scientific Impact Paper No. 6, September 2010.